What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad.

The scale of ambition should ring alarm bells. Sir David Nicholson, the NHS chief executive, has described the proposals as the biggest change management programme in the world—the only one so large “that you can actually see it from space.” (More ominously, he added that one of the lessons of change management is that “most big change management systems fail.”1) Of the annual 4% efficiency savings expected of the NHS over the next four years, the Commons health select committee said, “The scale of this is without precedent in NHS history; and there is no known example of such a feat being achieved by any other healthcare system in the world.”2 To pull off either of these challenges would therefore be breathtaking; to believe that you could manage both of them at once is deluded⇓.

Like all the other structural reorganisations of the NHS, this one aims to improve health outcomes. What’s lacking is any coherent account of how these particular reforms will produce the desired effects, a point only underlined by the prime minister’s attempts to justify the reforms earlier this week.3

This latest top down reorganisation has been whipped up in an awful hurry. It went unmentioned in the political manifestos of the coalition parties before the last general election, was specifically excluded in pledges given before and after the election, and didn’t make it into the Coalition Agreement of 20 May 2010. Yet less than eight weeks later, its outline emerged in the …